NATIONAL CONFERENCE OF BAR EXAMINERS (NCBE) Request for Preparation of a Character Report Fee Schedule

Transcription

1 NATIONAL CONFERENCE OF BAR EXAMINERS (NCBE) Request for Preparation of a Character Report Fee Schedule FEE CATEGORY II: FIRST BAR ADMISSION $200 III: ATTORNEY/BAR ADMISSION* $250 IV: FOREIGN Education OR $500 FOREIGN Practicing Attorney V: SUPPLEMENTAL REPORT (see fees below) Request that a character report previously prepared by NCBE be supplemented. NCBE will investigate the period from the completion of the original NCBE report to the present, including attempting to contact references. You are required to submit a complete application. A supplemental report can only be prepared if the original jurisdiction releases the original report and the conditions in the right-hand column are satisfied. DESCRIPTION Anticipated or recent law school graduate; AND JD was awarded less than one year before this application is received at NCBE; AND The applicant has not been admitted to the practice of law in any jurisdiction at the time this application is filed. Presently a member of a bar; OR Not a member of a bar, but the application is received at NCBE more than one year after the JD was awarded. Applicant's first law degree was not obtained in the U.S., whether or not a subsequent U.S. law degree was conferred; OR Member of a bar of a foreign country seeking to be licensed or to perform limited legal services. CONDITIONS The jurisdiction to which application is being made is willing to accept a copy of the original NCBE character report together with a supplemental report with the understanding that no additional work will be undertaken to verify the original report; AND The original NCBE report was completed less than four years before the date this request for supplemental report is received at NCBE. V(a): SUPPLEMENTAL REPORT * $125 Made previous application to a jurisdiction for which NCBE prepared the original report. V(b): SUPPLEMENTAL REPORT * $75 This report is for the same jurisdiction for which NCBE prepared the original Law Student Registrant report. V(c): SUPPLEMENTAL REPORT $200 The original NCBE report was processed as a Category IV Foreign report. *Applicants with foreign credentials (education or bar admission) are processed under Category IV or Category V(c) - see Fee Categories and Descriptions above. Check with the jurisdiction to which you are applying to determine if you should remit the fee directly to NCBE. METHOD OF PAYMENT STANDARD-07-DC Enclose payment (cashier s check, certified check, or money order payable to NCBE). Returned checks are subject to a $25 fee. Note that if you withdraw your application prior to the generation of correspondence, a processing fee will be retained. Once correspondence is generated, the entire fee is nonrefundable. In addition to the processing fee, NCBE reserves the right to pass along the cost of obtaining records in conjunction with this application. i

2 DIRECTIONS Answer all questions. If you answer affirmatively to certain questions you will be instructed to complete specific forms with more detailed information. These include Forms 1-10 which may be found at the end of the application. You may be required to make copies of some of the blank Forms 1-10; therefore, do not mark on a form until you have made the requisite number of copies. If you cannot make copies of the forms, you may obtain them by calling or writing the National Conference of Bar Examiners (NCBE) or you may obtain them online at by clicking on the Character and Fitness link. Your application will be processed only after you provide all the necessary information. To avoid delays, be sure to: Answer every question; do not leave anything blank. Complete all forms required. Sign all forms requiring your signature and have them notarized. Provide the correct number, street name, city, state, and zip code for each address. Include three original properly executed Authorization and Release Forms. Make your responses as concise as possible, using only standard abbreviations to make your information fit into the spaces provided. Some fields are deliberately restricted; if you need additional space to answer a question, attach a separate sheet of paper with the question number clearly identified. Use the two-letter codes to indicate state/territory names. For your convenience these codes are listed at the bottom of this page. Indicate dates in the following format: month/day/year. For example, October 5, 2001, should be written 10/05/2001. Consult with applicable courts, agencies, or other entities to obtain accurate and complete information if you are unsure of dates, locations, or other required information. This is your responsibility. Advise former employers and references that our agency may be contacting them. If you have any questions regarding these directions, you may contact NCBE at: National Conference of Bar Examiners 302 South Bedford Street Madison, WI Phone: (608) Fax: (608) TDD: (608) Website: contact@ncbex.org The two letter codes to indicate state/territory names are as follows: AL Alabama IL Illinois NE Nebraska PR Puerto Rico AK Alaska IN Indiana NV Nevada RI Rhode Island AZ Arizona IA Iowa NH New Hampshire SC South Carolina AR Arkansas KS Kansas NJ New Jersey SD South Dakota CA California KY Kentucky NM New Mexico TN Tennessee CO Colorado LA Louisiana NY New York TX Texas CT Connecticut ME Maine NC North Carolina UT Utah DE Delaware MD Maryland ND North Dakota VT Vermont DC District of Columbia MA Massachusetts MP Northern Mariana Islands VA Virginia FL Florida MI Michigan OH Ohio VI Virgin Islands GA Georgia MN Minnesota OK Oklahoma WA Washington GU Guam MS Mississippi OR Oregon WV West Virginia HI Hawaii MO Missouri PW Palau WI Wisconsin ID Idaho MT Montana PA Pennsylvania WY Wyoming ii

3 Name APPLICATION TO THE BAR OF DISTRICT OF COLUMBIA First Middle Last Social Security Number* LSAC Number: You are being asked to supply your LSAC number (a number assigned to you by the Law School Admission Council and implemented fairly recently by LSAC ), if you have one, on a voluntary basis. If you have received such a number from LSAC, you may access it through the following link: NCBE is studying the feasibility of using LSAC numbers as identifiers in lieu of Social Security Numbers for privacy reasons. In some cases, records are stored by institutions under the SSN; therefore, NCBE will continue to collect the SSN on a voluntary basis for use in situations in which records can only be accessed via SSN. APPLYING AS (choose one category): Motion/Reciprocity Applicant Bar Examination Applicant (exam date: ) (Mo/Yr) In-House Counsel Notary Public Foreign Legal Consultant (exam date: ) (Mo/Yr) List below all the other names or surnames you have used or been known by and describe when, how, and why your name was changed (e.g., marriage or divorce). First, Middle, Last Name Reason for change First, Middle, Last Name Reason for change From Year To Year From Year To Year Sex: Male Female Date of birth: Month Day Year Place of birth: City Country Of what country are you a citizen? If you are not a citizen of the United States, what is your immigration status? State Telephone numbers and address at which you can be reached during the next six months: ( ) ( ) Home Office Mailing address at which you can be contacted about this application during the next six months: Check if address is Residence or Business If business, name of firm /P.O. Box Code Country *Furnishing your Social Security Number (SSN) is voluntary pursuant to the Federal Privacy Act of Your SSN will be used for purposes of investigation and verification and will help avoid errors of identity which might introduce problems and delays into the certification and licensure process. For example, many educational institutions and law enforcement agencies can only access your records if the SSN is provided. 1

4 Make additional copies of this page as necessary 1. List every permanent and temporary street address where you have lived: If this is your first application prior to bar admission, provide your residency information for the last ten years or since age 18, whichever period of time is longer; OR If you have previously applied for bar admission or registered as a law student with a bar admitting authority, provide your residency information for the last ten years or since you were first admitted to the bar in any jurisdiction, whichever period of time is longer. List addresses in reverse chronological order starting with your current address. Current From Mo/Yr City County State Zip From Mo/Yr To Mo/Yr City County State Zip From Mo/Yr To Mo/Yr City County State Zip From Mo/Yr To Mo/Yr City County State Zip From Mo/Yr To Mo/Yr City County State Zip From Mo/Yr To Mo/Yr City County State Zip 2

5 EDUCATIONAL INFORMATION 2. List the names of all the colleges and universities you attended. Do not include law schools. Include location (including the name of the campus if the school had more than one), dates attended, and degree(s) received. Mark ND if you did not receive a degree. If the school's name has changed since your attendance, provide both its current name and former name. List schools beginning with the one most recently attended. College City Country/Province From Mo/Yr To Mo/Yr Degree College City Country/Province From Mo/Yr To Mo/Yr Degree 3. List the names of all the law schools you have attended or are currently attending. Include location (including the name of the campus if the school had more than one), dates attended, degree(s) received or expected to be received, and date degree(s) expected, if applicable. Mark ND if you did not receive a degree. If the school's name has changed since your attendance, provide both its current name and former name. List schools beginning with the one most recently attended. Law School City State Country/Province From Mo/Yr To Mo/Yr Degree Date Degree Expected Law School City State Country/Province From Mo/Yr To Mo/Yr Degree Date Degree Expected 4. Did you engage in law office study in lieu of receiving a JD? (This is permitted only in certain jurisdictions.) Yes No If yes, under the approval of what jurisdiction? Indicate when and where: From Mo/Yr To Mo/Yr Name of Firm Proctor Firm 5. Have you ever been dropped, suspended, warned, placed on scholastic or disciplinary probation, expelled, requested to resign, allowed to resign in lieu of discipline from any college or university (including law school), or otherwise subjected to discipline by any such institution or requested or advised by any such institution to discontinue your studies therein? Yes No If you answered yes, provide the following information: State State Name of the Institution Type of Action Explanation of Institution Action Date Action Taken 3

6 ADMISSION INFORMATION 6. PRIOR APPLICATIONS FOR ADMISSION List every state or foreign country to which you have submitted an application to take a bar examination or an application to be admitted to the bar by examination, motion, or diploma privilege. List every state or foreign country to which you have submitted an application to be reinstated to the bar. Include any preregistration as a law student. Do not list multiple application dates and examination dates in the same field; multiple applications and examinations to the same state or foreign country require separate entries. Provide a brief narrative explanation of the circumstances surrounding the reason for any withdrawals of applications or failures to be admitted (other than those due to failing the examination). In response to this question, DO NOT include information regarding admission to the U.S. federal courts or authorizations to appear pro hac vice. If admitted to a bar of a foreign country, indicate the name and address of the admitting authority in the explanation field. If admitted to the bar of Pennsylvania, complete FORM 9. If admitted to the bar of New York, indicate the judicial department to which admitted, and complete FORM 10. NONE: This is my first application for admission to practice law. State or foreign country Applied as: Bar Examinee Motion/Reciprocity Diploma Reinstatement Law Student Registrant Not admitted due to: Failed exam Withdrew application Other reason Pending Date application made (Mo/Yr) Date examination taken (Mo/Yr) Admitted or readmitted (Mo/Day/Yr) Bar Number* Explanation State or foreign country Applied as: Bar Examinee Motion/Reciprocity Diploma Reinstatement Law Student Registrant Not admitted due to: Failed exam Withdrew application Other reason Pending Date application made (Mo/Yr) Date examination taken (Mo/Yr) Admitted or readmitted (Mo/Day/Yr) Bar Number* Explanation State or foreign country Applied as: Bar Examinee Motion/Reciprocity Diploma Reinstatement Law Student Registrant Not admitted due to: Failed exam Withdrew application Other reason Pending Date application made (Mo/Yr) Date examination taken (Mo/Yr) Admitted or readmitted (Mo/Day/Yr) Bar Number* Explanation *If the jurisdiction does not issue a Bar Number leave this space blank. 4

7 LEGAL AND OTHER EMPLOYMENT INFORMATION 7. List every job you have held since age 21. All law-related employment must be listed. Follow these instructions: List most recent employment first. Include self-employment, externships, internships (paid and unpaid), clerkships, and military service. Include part-time employment. Include temporary employment. If you were employed by a temporary agency, provide the name, mailing address, and telephone number of the temporary agency and also note the name of the firm/company to which you were assigned. Account for any period of time when you were unemployed for more than three months (i.e., in school, studying for the bar examination, seeking employment, performing volunteer work, etc.). For these periods of time, check the box for Unemployment and describe the reason for your unemployment in the field labeled Position. Do not furnish your own name or the name of someone to whom you are related by blood or marriage as a confirming reference. CURRENT EMPLOYMENT Currently Unemployed Since Mo/Yr From Mo/Yr To PRESENT Position Employer or Firm Supervisor/Associate Employer or Firm Telephone ( ) If you are self-employed or employed by a relative, provide a reference who can verify the nature and length of your employment or practice. If you provide a business address, please include both the reference name and the business name. Name(s) Telephone ( ) 5

8 LEGAL AND OTHER EMPLOYMENT INFORMATION Make Additional Copies of this Page as Necessary DO NOT furnish your own name or your own contact information for verifying employment. From Mo/Yr To Mo/Yr Unemployment Period Position Employer or Firm Supervisor/Associate Employer or Firm (At time of employment) Telephone ( ) If the employer's/firm's name or address has changed, check this box and provide the current employer/firm information below. If you were self-employed, employed by a relative, or if the firm is out of business, check this box and provide a reference who can verify the nature and length of your employment or practice. If you provide a business address, please include both the reference name and the business name. Name(s) Telephone ( ) From Mo/Yr To Mo/Yr Unemployment Period Position Employer or Firm Supervisor/Associate Employer or Firm (At time of employment) Telephone ( ) If the employer's/firm's name or address has changed, check this box and provide the current employer/firm information below. If you were self-employed, employed by a relative, or if the firm is out of business, check this box and provide a reference who can verify the nature and length of your employment or practice. If you provide a business address, please include both the reference name and the business name. Name(s) Telephone ( ) 6

9 EMPLOYMENT AND PROFESSIONAL INFORMATION 8. Have you ever been terminated, suspended, disciplined, or permitted to resign in lieu of termination from any job? (If the employment was not previously listed, please go back and add it to Item 7.) Yes No If yes, provide the following about each occurrence: Employer or Firm Dates of Employment: From Mo/Yr To Mo/Yr Disposition: Terminated Suspended Disciplined Permitted to resign Explanation of circumstances: Employer or Firm Dates of Employment: From Mo/Yr To Mo/Yr Disposition: Terminated Suspended Disciplined Permitted to resign Explanation of circumstances: 9. List the full name and address of each mandatory or voluntary bar association of which you have been or are currently a member. Check here If you have never been a member. Name of Bar Association Dates of Membership: From Mo/Yr To Mo/Yr Name of Bar Association Dates of Membership: From Mo/Yr To Mo/Yr 10. A. Have you ever been disbarred, suspended, censured, or otherwise reprimanded or disqualified as an attorney? Yes No B. Have you ever been the subject of any charges, complaints, or grievances (formal or informal) concerning your conduct as an attorney, including any now pending? Yes No Check here if you have never been admitted to practice law. If you answered yes to 10A and/or 10B, please provide the following information for each matter: Name of Regulatory Agency Agency Action Explanation Date 7

10 CHARACTER AND FITNESS INFORMATION 11. Have you ever been the subject of any charges, complaints, or grievances (formal or informal) alleging that you engaged in the unauthorized practice of law, including any now pending? Yes No If the answer is yes, please provide the following information for each matter: Name of Regulatory Agency Agency Action Date Explanation 12. Have sanctions ever been entered against you, or have you ever been disqualified from participating in any case? Yes No Check here if you have never been admitted to practice law. If the answer is yes, please provide the following for each sanction or disqualification: Case No. Style of Action Name of Court Disqualified from Mo/Yr To Mo/Yr Reason for the sanction or disqualification Attach a copy of the order of sanction or disqualification. 13. Have you ever been a member of the armed forces of the United States, its reserve components, or the National Guard? Yes No If yes, complete FORM 1. 8

11 CHARACTER AND FITNESS INFORMATION 14. Have you ever held judicial office? Yes No If yes, provide the following information about each office: Office held From Mo/Yr To Mo/Yr Name of Court Reason for termination, if applicable Office held From Mo/Yr To Mo/Yr Name of Court Reason for termination, if applicable 15. Have you ever applied for a license (even if the application was subsequently withdrawn) or held a license for a business, trade, or profession, other than as an attorney-at-law? Yes No If yes, provide the following information about each license: Type of License Mo/Yr Current Status of License License Number (if applicable) Issuing Authority Type of License Mo/Yr Current Status of License License Number (if applicable) Issuing Authority 9

12 CHARACTER AND FITNESS INFORMATION 16. A. Have you ever been denied a license for business, trade, or profession (e.g., CPA, real estate broker, physician, patent practitioner)? Yes No B. Have you ever had a business, trade, or professional license revoked? Yes No If you answered yes to 16A and/or 16B, please provide the following information for each denial or revocation: Name of Regulatory Agency Agency Action Date Explanation 17. A. Have you ever been suspended, censured, or otherwise reprimanded or disqualified as a member of another profession, or as a holder of public office? Yes No B. Have you ever been the subject of any charges, complaints, or grievances (formal or informal) concerning your conduct as a member of any other profession, or as a holder of public office, including any now pending? Yes No If you answered yes to 17A and/or 17B, please provide the following information for each matter: Name of Regulatory Agency Agency Action Date Explanation 18. Has any surety on any bond on which you were the principal been required to pay any money on your behalf? Yes No If yes, complete FORM Have you ever been a named party to any civil action? Yes No NOTE: Family law matters (including continuing orders for child support) should be included here. If yes, complete a separate FORM 3 for each action. Attach a copy of the pleadings and final disposition. 10

13 CHARACTER AND FITNESS INFORMATION 20. Have you ever had a complaint or action (including, but not limited to, allegations of fraud, deceit, misrepresentation, forgery, legal malpractice) initiated against you in any administrative forum? Yes No If yes, complete a separate FORM 3A for each complaint or action. 21. A. Have you ever been cited for, arrested for, charged with, or convicted of any alcohol- or drug-related traffic violation? Yes No If yes, complete a separate FORM 5 for each incident. B. Have you been cited for, arrested for, charged with, or convicted of any moving traffic violation during the past ten years? (Omit parking violations.) Yes No If yes, report each incident on FORM 5T. NOTE: Your responses to Questions 21A and/or 21B must include matters that have been dismissed, expunged, subject to a diversion or deferred prosecution program, or otherwise set aside. 22. Have you ever been cited for, arrested for, charged with, or convicted of any violation of any law? (Report traffic violations at Questions 21.) Yes No If yes, complete a separate FORM 5 for each incident. NOTE: Include matters that have been dismissed, expunged, subject to a diversion or deferred prosecution program, or otherwise set aside. 23. Have you ever filed a petition for bankruptcy? Yes No If yes, complete a separate FORM 4 for each bankruptcy. 24. A. Have you had any debts of $500 or more (including credit cards, charge accounts, and student loans) which have been more than 90 days past due within the past three years? Yes No B. Have you ever had a credit card or charge account revoked? Yes No C. Have you ever defaulted on any student loan? Yes No D. Have you ever defaulted on any other debt? Yes No If yes to Questions 24A, 24B, 24C, and/or 24D, complete a separate FORM 6 for each debt. 11

14 CHARACTER AND FITNESS INFORMATION PREAMBLE TO QUESTIONS 25, 26, and 27 Notice to DC Applicants only: The Board of Judges of the District of Columbia Court of Appeals have adopted the following questions which must be answered by applicants for admission in the District of Columbia: 25. In the past five years, have you been addicted to or treated for or counseled concerning the use of any drug, including alcohol? Yes No If you answered yes, complete FORMS 7 and 8 as needed. 26. (There is no question 26.) 12

15 CHARACTER AND FITNESS INFORMATION 27. In the past five years, have you voluntarily entered or been involuntarily admitted to an institution for treatment of a mental, emotional, or nervous disorder or condition? Yes No If you answered yes, complete Forms 7 and 8 and furnish a thorough explanation below: If you were involuntarily admitted list the name of the entity that authorized the admission (i.e., court, agency, official, etc.) Telephone ( ) Explanation 13

16 PERSONAL AND PROFESSIONAL REFERENCES 28. Provide the names and addresses of at least six references, preferably persons who have known you for a minimum of five years. You are encouraged to include one reference from every locality where you have lived during the last ten years. Do not list yourself, anyone who is related to you by blood or marriage, or anyone who resides at your current residential address. Do not use names listed in response to Item 7 (employment). If you provide a business address, please include both the reference name and the business name. Name(s) Telephone ( ) Occupation Name(s) Telephone ( ) Occupation Name(s) Telephone ( ) Occupation Name(s) Telephone ( ) Occupation Name(s) Telephone ( ) Occupation Name(s) Telephone ( ) Occupation Years known Years known Years known Years known Years known Years known 14

17 ATTESTATION I hereby certify that I have read the foregoing document, and that the information that I have provided on this form and in any related materials is true and complete. I will notify the Committee on Admissions promptly in writing if there is any change in any aspect of this application. I understand that this is a continuing obligation throughout the pendency of my application, and that any inaccurate, misleading or incomplete statements, or any failure to update promptly any aspect of this application, may result in denial of this application and other disciplinary sanctions. I have not modified the questions in any respect, and I understand that should they be modified, my application will be terminated and any fees paid to NCBE are forfeited. STATE OF COUNTY OF } ss. Signature of Applicant Subscribed and sworn to or affirmed before me this day of, Month Year Notary Public My commission expires Seal or stamp must be affixed to each original. Attach three original notarized copies of the Authorization and Release Form. 15

18 Authorization and Release Form DO NOT ALTER THESE FORMS Execute Three Original Copies Please Use Black or Blue Ink AUTHORIZATION AND RELEASE I, (Name), born at (City), (State), (COUNTRY), on (Date of Birth), having filed an application with the admission authority of the bar of as one (Jurisdiction) of the following: Motion/Reciprocity Applicant, Bar Examination Applicant, In-House Counsel, Notary Public, or Foreign Legal Consultant, hereby apply for a character report to be prepared by the National Conference of Bar Examiners. I further consent to the National Conference of Bar Examiners conducting an investigation as to my moral character, professional reputation, and fitness for the practice of law. I further agree to provide additional information which may be required concerning my past record. I understand that the contents of my character report are confidential and shall be reported only to bar admissions authorities for the purpose of making a determination regarding my character and fitness to practice law. I also authorize and request every person, firm, company, corporation, association, court, school, college, university, other educational institution, governmental agency, law enforcement agency, and any other agency having control of any records, files, documents, writings or other information pertaining to me to furnish to the National Conference of Bar Examiners any such information regarding any and all (including those dismissed or otherwise erased or expunged by law, whether formal or informal, pending or closed) charges, complaints, disciplinary actions, grievances, sanctions, suspensions, reprimands, disqualifications, censures, resignations, terminations, citations, arrests, indictments, convictions, judgments, court-martials, non-judicial punishments, administrative discharges, or any other pertinent data or information pertaining to me. I further authorize the National Conference of Bar Examiners or any of its agents or representatives to inspect and make copies of such documents, records, or other information. The records, however, will not include any information with respect to a juvenile offense. I authorize the National Personnel Records Center in St. Louis, MO, or other custodian of my military record to release to the National Conference of Bar Examiners information or photocopies from my military record. I hereby release, discharge, and exonerate the National Conference of Bar Examiners, its agents and representatives, the admitting authority of the above jurisdiction, its agents and representatives, and any person so furnishing information from any and all liability of every nature and kind arising out of the furnishing or inspection of such documents, records, and other information, or the investigation made by the National Conference of Bar Examiners or by the admitting authority. STATE OF COUNTY OF } ss. ss. Signature of Applicant Subscribed and sworn to or affirmed before me this of, Month Year day Notary Public My commission expires Seal or stamp must be affixed to each original. 16

19 Authorization and Release Form DO NOT ALTER THESE FORMS Execute Three Original Copies Please Use Black or Blue Ink AUTHORIZATION AND RELEASE I, (Name), born at (City), (State), (COUNTRY), on (Date of Birth), having filed an application with the admission authority of the bar of as one (Jurisdiction) of the following: Motion/Reciprocity Applicant, Bar Examination Applicant, In-House Counsel, Notary Public, or Foreign Legal Consultant, hereby apply for a character report to be prepared by the National Conference of Bar Examiners. I further consent to the National Conference of Bar Examiners conducting an investigation as to my moral character, professional reputation, and fitness for the practice of law. I further agree to provide additional information which may be required concerning my past record. I understand that the contents of my character report are confidential and shall be reported only to bar admissions authorities for the purpose of making a determination regarding my character and fitness to practice law. I also authorize and request every person, firm, company, corporation, association, court, school, college, university, other educational institution, governmental agency, law enforcement agency, and any other agency having control of any records, files, documents, writings or other information pertaining to me to furnish to the National Conference of Bar Examiners any such information regarding any and all (including those dismissed or otherwise erased or expunged by law, whether formal or informal, pending or closed) charges, complaints, disciplinary actions, grievances, sanctions, suspensions, reprimands, disqualifications, censures, resignations, terminations, citations, arrests, indictments, convictions, judgments, court-martials, non-judicial punishments, administrative discharges, or any other pertinent data or information pertaining to me. I further authorize the National Conference of Bar Examiners or any of its agents or representatives to inspect and make copies of such documents, records, or other information. The records, however, will not include any information with respect to a juvenile offense. I authorize the National Personnel Records Center in St. Louis, MO, or other custodian of my military record to release to the National Conference of Bar Examiners information or photocopies from my military record. I hereby release, discharge, and exonerate the National Conference of Bar Examiners, its agents and representatives, the admitting authority of the above jurisdiction, its agents and representatives, and any person so furnishing information from any and all liability of every nature and kind arising out of the furnishing or inspection of such documents, records, and other information, or the investigation made by the National Conference of Bar Examiners or by the admitting authority. STATE OF COUNTY OF } ss. ss. Signature of Applicant Subscribed and sworn to or affirmed before me this of, Month Year day Notary Public My commission expires Seal or stamp must be affixed to each original. 17

20 Authorization and Release Form DO NOT ALTER THESE FORMS Execute Three Original Copies Please Use Black or Blue Ink AUTHORIZATION AND RELEASE I, (Name), born at (City), (State), (COUNTRY), on (Date of Birth), having filed an application with the admission authority of the bar of as one (Jurisdiction) of the following: Motion/Reciprocity Applicant, Bar Examination Applicant, In-House Counsel, Notary Public, or Foreign Legal Consultant, hereby apply for a character report to be prepared by the National Conference of Bar Examiners. I further consent to the National Conference of Bar Examiners conducting an investigation as to my moral character, professional reputation, and fitness for the practice of law. I further agree to provide additional information which may be required concerning my past record. I understand that the contents of my character report are confidential and shall be reported only to bar admissions authorities for the purpose of making a determination regarding my character and fitness to practice law. I also authorize and request every person, firm, company, corporation, association, court, school, college, university, other educational institution, governmental agency, law enforcement agency, and any other agency having control of any records, files, documents, writings or other information pertaining to me to furnish to the National Conference of Bar Examiners any such information regarding any and all (including those dismissed or otherwise erased or expunged by law, whether formal or informal, pending or closed) charges, complaints, disciplinary actions, grievances, sanctions, suspensions, reprimands, disqualifications, censures, resignations, terminations, citations, arrests, indictments, convictions, judgments, court-martials, non-judicial punishments, administrative discharges, or any other pertinent data or information pertaining to me. I further authorize the National Conference of Bar Examiners or any of its agents or representatives to inspect and make copies of such documents, records, or other information. The records, however, will not include any information with respect to a juvenile offense. I authorize the National Personnel Records Center in St. Louis, MO, or other custodian of my military record to release to the National Conference of Bar Examiners information or photocopies from my military record. I hereby release, discharge, and exonerate the National Conference of Bar Examiners, its agents and representatives, the admitting authority of the above jurisdiction, its agents and representatives, and any person so furnishing information from any and all liability of every nature and kind arising out of the furnishing or inspection of such documents, records, and other information, or the investigation made by the National Conference of Bar Examiners or by the admitting authority. STATE OF COUNTY OF } ss. ss. Signature of Applicant Subscribed and sworn to or affirmed before me this of, Month Year day Notary Public My commission expires Seal or stamp must be affixed to each original. 18

21 To be used with Question 13 FORM 1 / MILITARY SERVICE Name First Middle Last Social Security Number I am presently a member of the armed forces. I was a member of the armed forces. A. Regular armed forces: Air Force Army Coast Guard Marine Corps Navy Reserve components: Air Force Army Coast Guard Marine Corps Navy National Guard: Air Force Army My serial number was/is My rank was/is Dates of service: Active Duty - From Mo/Yr To Mo/Yr Reserve Duty - From Mo/Yr To Mo/Yr Nat'l Guard - From Mo/Yr To Mo/Yr ATTACH COPIES OF ALL OF YOUR REPORTS OF SEPARATION (e.g., DD FORM 214-MEMBER COPY #4, NGB FORM 22, ETC.). THE DD FORM 214 THAT YOU PROVIDE MUST INDICATE YOUR CHARACTER OF SERVICE. B. For ACTIVE AND RESERVE PERSONNEL ONLY: Check Active Reserve Present duty station Telephone number ( ) Name of commanding officer C. As a member of the armed forces of the United States: 1. Were you ever court-martialed? *Yes No 2. Were you ever awarded non-judicial punishment? (Art.15 UCMJ) *Yes No If you are presently a member of the armed forces, do not answer Questions 3, 4, and Did you receive an honorable discharge? Yes *No 4. Were you allowed to resign in lieu of court-martial? *Yes No 5. Were you administratively discharged? *Yes No *If you checked a box followed by an asterisk, provide an explanation for each answer: Refers to Item C (1, 2, 3, 4, or 5) Date of Action Explanation of circumstances Result, including any punishment Refers to Item C (1, 2, 3, 4, or 5) Explanation of circumstances Date of Action Result, including any punishment Form 1 19

22 To be used with Question 18 FORM 2 / BONDING COMPANIES Name First Middle Last Social Security Number Name and complete address of surety (bonding company): Name of surety Amount of money paid by surety Date money paid Reason for bond Brief explanation Form 2 20

23 To be used with Question 19 FORM 3 / RECORD OF CIVIL ACTIONS Name First Middle Last Social Security Number Complete title of action Court file number Date filed Name and complete address of court involved: Name of court Plaintiff's name Plaintiff's attorney Defendant's name Defendant's attorney Trial Date Date of final disposition Disposition Are you the subject of any continuing court order (e.g., for child support or payment of a money judgment)? Yes No If the disposition resulted in a judgment, has the judgment been satisfied? Yes No Not Applicable (Disposition did not result in a judgment.) If yes, give the date the judgment was satisfied If no, what amount is still owing? Brief explanation of suit Attach a copy of the pleadings, judgments and/or final orders. Form 3 21

24 To be used with Question 20 FORM 3A / RECORD OF ADMINISTRATIVE ACTIONS Name First Middle Last Social Security Number Date action/complaint initiated: Name and complete address of administrative forum or body: Name of administrative forum or body Name and complete address of investigative agency (body, board, commission, committee, etc.): Name of agency Disposition Date of final disposition Brief explanation Attach a copy of the administrative record. Form 3A 22

25 To be used with Question 23 FORM 4 / RECORD OF BANKRUPTCY OR INSOLVENCY Name First Middle Last Social Security Number Date bankruptcy filed Complete title of action Court file number Name and complete address of court involved: Name of court Debts Discharged: Credit Grantor Account Number Amount Discharged Date of final disposition Disposition Were any adversary proceedings instituted? Yes No Were there any allegations of fraud? Yes No Were any debts not discharged? If yes, answer Question 24 and complete FORM 6. Yes No Brief description of circumstances surrounding filing petition for bankruptcy: Attach a schedule of indebtedness, the petition for bankruptcy, and discharge from bankruptcy order. Form 4 23

26 To be used with Questions 21A and 22 FORM 5 / RECORD OF CRIMINAL CASES Name First Middle Last Social Security Number Date (or time period) of incident Charge(s) on date of arrest or citation Location City County State Title of complaint, indictment, or citation Case number Name and complete address of court involved: Name of court Name and address of law enforcement agency involved: Name of law enforcement agency Name and address of defendant's attorney: Name of attorney Date of initial court hearing Charge(s) at time of initial court hearing Date of final disposition Charge(s) at time of final disposition Final disposition Brief description of incident Attach a copy of the arresting agency's report, complaint, indictment, citation, information, disposition, sentence, and appeal, if any. Form 5 24

27 To be used with Question 21B FORM 5T / RECORD OF MOVING TRAFFIC VIOLATIONS Name First Middle Last Social Security Number Currently licensed in State Driver's License number Traffic violations involving alcohol or drugs should be reported in response to Question 21A and on FORM 5. Please complete the following information for each incident: Name of law enforcement agency Incident location (city, county, state) Date of incident (Mo/Yr) Charge(s) on date of incident Date of final disposition (Mo/Yr) Charge(s) at time of final disposition Final disposition Brief description of incident Name of law enforcement agency Incident location (city, county, state) Date of incident (Mo/Yr) Charge(s) on date of incident Date of final disposition (Mo/Yr) Charge(s) at time of final disposition Final disposition Brief description of incident Name of law enforcement agency Incident location (city, county, state) Date of incident (Mo/Yr) Charge(s) on date of incident Date of final disposition (Mo/Yr) Charge(s) at time of final disposition Final disposition Brief description of incident Form 5T 25

28 To be used with Question 24 FORM 6 / DEBTS: Defaults; Past Due; Revocations Name First Middle Last Social Security Number This copy of FORM 6 refers to QUESTION 24 A B C D Type of debt: Credit Card Charge Account Student Loan Other If this debt was discharged in bankruptcy, check here and do not complete the rest of the form: Account Number Original Amount of Debt Current Balance Date of Last Payment Name and complete address of entity extending credit: Name of entity Telephone Number ( ) If different from above, current name and address of the creditor on this debt: Name Telephone Number ( ) Account Number Current status of this debt Describe the history of this debt, including any actions taken to collect and any defenses: Form 6 26

29 To be used with Questions 25 and 26 FORM 7 / AUTHORIZATION TO RELEASE MEDICAL RECORDS Upon presentation of the original or a photocopy of this signed authorization, I (Applicant's Name) authorize Name of Institution, Doctor, or Counselor to provide information, including copies of records, concerning advice, care, or treatment provided to me, without limitation relating to mental illness or the use of drugs or alcohol, to representatives of the National Conference of Bar Examiners who are involved in conducting an investigation into my moral character, professional reputation, and fitness for the practice of law. I understand that any such information as may be received will be reported only to the admitting authority. I hereby release, discharge and exonerate the National Conference of Bar Examiners, its agent and representatives, the admitting authority, its agent and representatives, and (Name of Institution, Doctor, or Counselor), their agents and representatives so furnishing information from any and all liability of every nature and kind arising out of the furnishing or inspection of such documents, records and other information, or the investigation made by the National Conference of Bar Examiners or the admitting authority. Signature of Applicant Subscribed and sworn to or affirmed before me this of, Month Year day Notary Public My commission expires Seal or stamp must be affixed to each original. The National Conference of Bar Examiners is aware of your obligations under HIPAA. Form 7 27

30 To be used with Questions 25 and 26 FORM 8 / DESCRIPTION OF MENTAL HEALTH OR SUBSTANCE ABUSE CONDITION OR IMPAIRMENT Name First Middle Last Social Security Number Dates of treatment: From Mo/Yr To Mo/Yr Name and complete address of attending physician or counselor: Name of physician or counselor Physician's or Counselor's current address Telephone ( ) Name and complete address of hospital or institution: Name of hospital or institution Hospital's or Institution's current address Telephone ( ) Describe the condition or problem Describe any treatment and/or monitoring program The National Conference of Bar Examiners is aware of your obligations under HIPAA. Form 8 28

31 To be used with Question 6 FORM 9 SUPREME COURT OF PENNSYLVANIA Name Attorney I.D. Number Date of Admission Place of Admission: EASTERN DISTRICT MIDDLE DISTRICT WESTERN DISTRICT (Philadelphia) (Harrisburg) (Pittsburgh) FOR OFFICIAL USE ONLY (Please DO NOT write inside this box) A.O.P.C.: D.B.: P.B.L.E.: Date remitted: To be used with Question 6 FORM 10 FOR APPLICANTS PREVIOUSLY ADMITTED IN NEW YORK Name Date of Admission Department in which you were admitted (check one): First Department Second Department Third Department Fourth Department Department(s) in which you have practiced law or been employed as an attorney (check ALL that apply and include county): I have not practiced law in any department in New York First Department; County(ies) Second Department; County(ies) Third Department; County(ies) Fourth Department; County(ies) Form 9 & Form 10 29